Women Who Use Drugs and Female Partners of Men Who Use Drugs

Opioid agonist therapy, particularly maintenance programs with methadone and buprenorphine, leads to reduction in drug use, HIV acquisition and risk behavior among PWID, is safe and effective for use by pregnant women.

Some women are particularly at risk of HIV acquisition due to their occupational exposures, their behavior or that of their sexual partner(s), their sexual identity and/or their sexual orientation. These women live in particularly challenging situations and have high vulnerability to HIV infection and low access to HIV services (Beyrer et al., 2011). UNAIDS defines key populations as those most likely to be exposed to HIV or to transmit HIV and therefore are key to the epidemic and the response (UNAIDS, 2011e). These groups of women—sex workers, people who inject drugs (PWIDs) or female partners of PWIDs, transgendered people, migrant women and female partners of male migrants, women prisoners and female partners of male prisoners, women and girls in complex emergencies and women who have sex with women—have specific needs in prevention and are often marginalized within their societies. [Men who have sex with men (MSM) are also a key population, however this group is beyond the scope of this resource. For evidence-based interventions for this population, please refer to Beyrer et al., 2011.]

Key affected populations often face significant barriers in access to prevention services, testing and treatment. “…Transgender persons, commercial sex workers, and injecting drug users suffer stigma and discrimination that threaten their rights and well-being and impede their access to HIV/AIDS services” (IOM, 2011: 153). “Too often national AIDS plans omit these people who face formidable legal and other structural barriers to accessing HIV services” (Chan et al., 2011). Other lesser-recognized populations at high risk for HIV acquisition are women who serve in their country’s military or in peacekeeping missions (Essien et al., 2010; Biague et al., 2010). In addition, some have argued that married heterosexual women in many countries are a key affected population. For example, in India and Cambodia, HIV prevalence is higher among married than unmarried women (Greener and Sarkar, 2010). Precisely because these married women are not considered a key affected population for HIV prevention, they may be less likely to consider themselves at risk or have adequate knowledge about HIV and/or have access or the power to ensure safe sex. [See Prevention for Women]

HIV prevention is not being scaled up to the extent needed among vulnerable groups. In Asia, less than one in two sex workers and only one in five PWIDs are reached with HIV prevention services. Yet modeling suggests that 60 to 80% coverage of key populations is required to reduce HIV incidence (Low-Beer and Sarkar, 2010). As of 2011 in South Africa, no national programs existed for key populations, with most services being provided by NGOs (Scheibe et al., 2011). Without addressing the needs of these key affected populations, HIV incidence will continue to escalate (Bridge et al., 2010).

“Key populations at higher risk of HIV infection” are often not reached with HIV testing and counseling, a gateway to treatment (WHO et al., 2011b: 76). Access to antiretroviral therapy in key populations must be promoted to ensure good health outcomes, promote equity, and because antiretroviral therapy access in these populations will decrease HIV incidence in the whole population (Schwartlander et al., 2011). Yet health workers may face prosecution for providing health services to key affected populations in countries where same sex behavior, sex work or drug use is illegal (Scheibe et al., 2011). Some have suggested that key affected populations may be good candidates for pre-exposure prophylaxis (El-Sadr, 2012; Baeten, 2012), though the ethics and cost effectiveness of this strategy must be further explored.

The pandemic remains dynamic: for example, while injecting drug use has been a risk factor in Eastern Europe, it is emerging as a risk factor in Africa and simple dichotomies of concentrated versus generalized epidemics no longer characterize these complexities (Beyrer et al., 2011). While public health epidemiology can clarify which groups in which countries are the most at risk of HIV acquisition, an understanding is needed of overlapping risk behaviors and the fluidity between some groups. For example, sex workers are rarely considered as the focus of PMTCT programs, despite abundant evidence that sex workers get pregnant and have children. In some parts of the world, substantial overlap occurs between sex work and drug use: an estimated 20–50% of female injecting drug users in Eastern Europe and 10–25% of female injecting drug users in Central Asia are involved in sex work (Rhodes et al., 2002 cited in Pinkham et al., 2008). In many places, HIV prevalence among sex workers who inject drugs is higher than it is among either non-sex worker PWIDs or non-drug using sex workers (Pinkham and Malinowska-Sempruch, 2008). Further, in many countries, prison is a common experience for people who inject drugs, including women (Du Cros and Kamarulzaman, 2006). While the numbers of women who have sex with women (WSW), particularly those who are at risk of HIV acquisition, are small, WSW have been ignored and are therefore included here (Henderson et al., 2011).

The prevention needs of the groups of women listed below and the overlap between them must be considered for HIV prevention planning to be maximally effective. These groups are discussed in more depth in the following sections.